Jane E Scullion Provides 11 Top Tips to Help Primary Care Empower Adult Patients to Achieve Optimal Asthma Control
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Although asthma is common and its diagnosis should, therefore, be easy, there is no one definitive test that allows us to be fully confident that a person has asthma. Instead, we must examine factors that may lead us to consider a diagnosis of asthma, backed up by the use of diagnostic tools and by our choice of medications. If it is asthma, then it should respond to asthma therapies, but we will need to review our actions.
The first prompt will be the symptoms that a person presents with. Asthma can occur at any age; commonly recognised symptoms include cough, wheeze, shortness of breath, chest tightness, and worsening of these symptoms at night or on wakening.1,2 These symptoms can vary in intensity over time and from patient to patient, and may be brought on by recognisable triggers.1
1. Get the Diagnosis of Asthma Right by Taking a Good History
A good history will take into account many factors, including childhood respiratory problems, history of allergy, family history of asthma or allergy, occupation and change in occupational working practices, hobbies, pets, housing, changes in circumstances including social circumstances, medication use, comorbidity, and current or previous smoking of tobacco or other substances.1,2 It may also be worth asking about vaping habits as, although vaping is not formally recognised as a trigger for asthma, growing evidence suggests that the use of e-cigarettes causes short-term airway inflammation in patients with asthma.3
2. Recognise the Many Triggers That can Cause Asthma
Environmental triggers comprise indoor risk factors, outdoor risk factors, and risk factors that may be both indoor and outdoor.4 Indoor triggers include animals, house dust mites, and insects such as the cockroach.4 Outdoor triggers include extremes of temperature, rain and thunderstorms, and droughts.4 Triggers that may be encountered both indoors and outdoors include tobacco smoke and vaping, pollen, mould spores, viruses, dust, air pollutants, and chemical irritants and fumes.4
Other triggers for asthma include exercise, diet, medication use, and obesity.4
3. Be Familiar with the Different Phenotypes of Asthma
Although we commonly group all types of asthma under one umbrella term, understanding that there are different phenotypes of asthma can help us to work towards a more robust diagnosis.
Allergic asthma is perhaps the most readily recognisable phenotype. Often, there has been a childhood diagnosis of asthma and an association with allergic disease, either in the person presenting with symptoms or in a family member.2 Common associations with asthma are eczema, food or drug allergy, and allergic rhinitis.2 People with suspected allergic asthma often have sputum or blood eosinophilia, and most exhibit a good response to inhaled corticosteroids (ICSs).2
In people with nonallergic asthma, the sputum can be neutrophilic or eosinophilic, or there may be very few inflammatory cells.2 This asthma phenotype is less responsive to ICSs in the short term.3
Late- or adult-onset asthma is asthma that occurs for the first time in adult life.2 It appears to be more common in women and in those without allergies.2 Although late-onset asthma can be more refractory to ICS treatment, higher doses of ICSs may help with symptoms and control.2
Asthma with Fixed Airflow Obstruction
Asthma with fixed airflow obstruction, also termed asthma with persistent airflow limitation, is thought to be due to airway remodelling, which can be caused by smoking, poorly controlled inflammation over time, nonadherence to treatment, inadequate ICS dose, or a combination of these factors.1,2,5
Asthma with Obesity
Some patients with asthma and obesity have very prominent respiratory symptoms, with little evidence of eosinophilic inflammation.2 Obesity is a risk factor for asthma, and people with obesity and asthma often have more severe symptoms and a reduced response to treatment than individuals with asthma who are not obese.6
4. Assess People with Risk Factors for Asthma
Risk factors for asthma include a mix of genetic, epigenetic, and environmental factors.4 Genetics is concerned with characteristics we inherit from our parents, and epigenetics is the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code. Although we may be able to modify environmental factors, we can do little to alter genetic or epigenetic factors.
When assessing risk, looking at a person’s current control can help us to understand their health-related quality of life and future risk.7,8 Control is defined as no night-time awakenings due to asthma, minimal symptoms, little requirement for rescue medication, minimal side effects from medication, normal lung function, and no visits to the accident and emergency department.9 If control is good, then exacerbations, unstable or worsening symptoms, and side effects from medication should be reduced, and loss of lung function and, ultimately, death can be avoided.2,9
Those at high risk of severe asthma should be closely monitored, and we should be cognisant of the features that increase the risk of asthma exacerbations and death, such as a prior accident and emergency visit, hospital admission, or an intensive care unit admission for asthma.8
5. Understand the Tools Available to Reinforce a Diagnosis of Asthma
Diagnostic tools, such as questionnaires and tests, can be used alongside consultation skills to assess the severity of symptoms and response to treatment.
Peak Expiratory Flow Rate
Peak expiratory flow rate, which measures maximum speed of expiration, is perhaps one of our most useful tools: it allows us to ascertain diurnal variability and response to treatment, and it gives us an idea of the person’s best measurement and when they may be running into problems. However, the caveat is that it is often poorly performed, can yield inconsistent results, and may be more useful for monitoring occupational asthma.1
Although it is the investigation of choice for identifying airway obstruction,1 spirometry has become problematic during the COVID-19 pandemic because it is an aerosol-generating procedure that has the potential to spread infection to staff and patients.2 Therefore, the technique has necessarily become less widely used.
Fractional Exhaled Nitric Oxide
Fractional exhaled nitric oxide (FeNO) is a measure of the level of nitric oxide in the breath, and is a useful measure of inflammation, response to ICSs, and adherence to ICS treatment.2 It is less useful as a stand-alone diagnostic tool because inflammation can occur for many reasons.2 The Global Initiative for Asthma (GINA) report advises that low initial FeNO cannot be used as a reason to withhold ICS treatment.2
Asthma control can be monitored using the Royal College of Physicians (RCP) 3 Questions for Asthma (see Figure 1),10 the GSK Asthma Control Test™,11 the Asthma Control Questionnaire,12 or simply by asking patients ‘What does your asthma prevent you from doing?
6. Consider Lifestyle Interventions as well as Pharmacological Treatments
Smoking cessation is as important an intervention in asthma as it is in chronic obstructive pulmonary disease (COPD), yet we often fail to recognise this. Research has shown that many people with asthma smoke at levels relatively close to those evident in the general population,13 and we need to remember that this may not just be cigarettes.
Two vaccinations are recommended for some people with asthma. The flu vaccine is advised for patients with asthma who are taking inhaled or systemic steroids, or who have experienced previous exacerbations requiring a hospital admission.14 The pneumococcal vaccine is recommended for patients with severe asthma that requires the use of systemic steroids, and anyone over the age of 65 years.15
Relaxation and breathing exercises can help with symptoms of asthma, especially if people are overbreathing or shallow breathing.2,16 Similarly, anxiety management can help those who overbreathe and are anxious because of their diagnosis or lifestyle.16
Weight loss is important, as is exercise—one important message for people with asthma is that, if controlled, the condition should not limit them from exercise, even at the highest levels.
7. Use Appropriate Pharmacological Interventions in Accordance with Local, National, and International Guidelines
The British Thoracic Society/Scottish Intercollegiate Guidelines Network guidance1 and the GINA report2 are the most commonly used recommendations on the use of pharmacological interventions, and these may be adapted locally, often with local guidance on formulary-recommended treatments. Some local formularies may be quite open; others will have a more restricted formulary. Perhaps the biggest change in recent times has been the emphasis on ICSs as the first-line treatment of choice.1,2
8. Check Patients’ Inhaler Technique, Adherence, and Views on Medication
The fundamental treatments for asthma are delivered by inhaler devices. Inhaled medication reaches the lung and acts with fewer systemic side effects compared with oral medications.17
Matthys et al. asserted that our best management strategies will come to nothing unless we have discussed the ideas, concerns, and expectations of the patient.18 Whatever medication or device we choose to treat a person’s asthma, it will not have the desired impact unless the treatment selection process involves the person with asthma and considers their concerns, ideas, or expectations with regard to their diagnosis and treatment.
At every review, a person’s inhaler technique should be assessed because people often forget instructions; patients can also be directed to good instructional videos, such as those on the RightBreathe (www.rightbreathe.com) or Asthma UK (www.asthma.org.uk) websites.19,20
9. Empower Self-management in All People with an Asthma Diagnosis
Personal asthma action plans that help patients to recognise symptoms and exacerbations and understand what action to take are fundamental to empowering people with asthma to take control of their condition.21
We must work through personal asthma action plans with our patients and engage in discussion to draw up a management plan for the future. This should be shared, open and constructive, and based on our patients’ and their carers’ views.
10. Undertake a Personalised Review
NICE Quality Standard (QS) 25 states that people with asthma should undergo a structured review at least once a year.22 NICE states that the measures identified in QS25, including structured review, can be expected to contribute to improvements in outcomes such as increased health-related quality of life, reduced absence from school or work, less frequent asthma attacks, and fewer hospital and accident and emergency department attendances.22 Structured reviews are an essential component of good asthma care.23
Alongside structured reviews, we also need to evaluate a patient’s response to treatment. Monitoring inhaler pick up rates should help with this, keeping in mind that we should be non-judgemental and recognise that sometimes people simply forget or that life gets in the way, while also being vigilant for red flags.
We also need to consider that many people have other conditions that coexist with asthma, such as COPD, bronchiectasis, rhinitis, reflux, sinusitis, and obesity. If we recognise and treat these comorbid conditions, it can improve overall asthma control.24
11. Know When to Refer Someone with Asthma
Patients should be referred to a specialist when their asthma cannot be controlled, when you are querying the diagnosis, or when you think there is a requirement for a biologic.1 A specialist asthma service does not have to be in a hospital—it may be provided by a primary care healthcare professional with a special interest in, or specialised knowledge of, asthma management—although, in the case of biologics, these are only initiated in secondary care at present.
It is important to remember the red flags for the risk of an asthma attack, such as unscheduled emergency contact, hospitalisation, or frequent use of a short-acting beta2-agonist, and also the red flags of symptoms and signs that do not appear to fit an asthma diagnosis.1
Asthma is a common but treatable condition, and correct management can greatly improve the lives of the people living with it and reduce the risk of complications. The 11 top tips discussed in this article provide useful advice for the management of asthma in primary care.
Jane E Scullion
Consultant Respiratory Nurse, University Hospitals of Leicester
At the time of publication (September 2021), some of the drugs discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.